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Health Maintenance Organization (HMO)

People enroll in an HMO through an employer, who either covers the entire premium or a portion of it, with the remaining cost deducted from the participating employee’s payroll.  You can also enroll in an HMO through the Affordable Care Act Exchanges or as part of your Medicaid plan.

Insurance InfoAn HMO is a type of managed care health plan where members choose their physician from a network of approved health care providers which typically results in lower premiums and/or copayments. Generally, members of an HMO can only see a health care specialist (hematologist, cardiologist, rheumatologist) if they get a referral from their primary care physician, also known as a gatekeeper. Your primary care physician serves as your health care advocate and will help you find the best treatment for physical and mental health problems you might face. HMOs tend to provide the least expensive medical coverage. However, your choice of physicians may be more limited.

The benefits of a Health Maintenance Organization (HMO) can differ depending on the company and group plan. Make sure you understand the specific benefits offered by your HMO policy and ask questions if you are confused or unsure about the HMO’s benefits. Be sure to review the Summary Plan Description (SPD), which is the part of the HMO policy that outlines the different benefits provided by your employer or insurance company.

Bleeding Disorder Specifics

  • If you are with an HMO, please be sure to have a primary care physician (PCP) and see that physician (right away if he/she is new to you) to get referrals to your HTC for care, medication, and factor coverage. Your insurance plan will not pay your claims without a referral from your PCP.
  • Some insurance policies require a prior authorization for factor or medications. This can take one to seven days to obtain. Order early to insure your factor will be to you on time.